New Patient Questionnaire

New Patient Questionnaire

New patients are always welcome at Ottawa Foot Clinic. We are committed to providing the best quality of care and patient experience to those who bring their nail, foot and ankle problems to our close attention. Please feel free to learn more about our practice and our services if you have not already.A first-time visit to any clinic may be a bit overwhelming: some important information about your health status and specific foot condition(s) may be skipped if the process of filling your intake form is rushed in any way or completed outside your home environment. You will most likely end up with a much better overall examination and results if you make time to get your case very well prepared before your first appointment. This is why we offer you the option to complete your New Patient Questionnaire way in advance, in the comfort of your home, to provide your foot specialist with a clear and precise picture of your overall case history, specific foot issue(s) over time and, of utmost importance, your goal such as getting:

getting back to your game or preferred physical activity by April 15!

getting clear nails back on your toes for your next summer vacations!

getting rid of your plantar wart before your graduation party!!

getting your ingrown toenail fixed as soon as possible!!

The New Patient Questionnaire can be filled out directly online and sent to us in a complete secure way so your privacy is fully protected.

You may as well download the pdf version of the New Patient Questionnaire, print it out and complete it , having all necessary information at hands. You may then email it, fax it or bring it with you at the time of your first appointment. This will save you 15 minutes upon arrival, especially if you intend to arriving right on time – yes, we know how tight is your schedule is! Plus it will give your foot specialist the very valuable opportunity to review your questionnaire in advance in order to get prepared to serve you the best possible way, namely in getting to the point much faster, with much more clarity!

If you have any further questions about what you may expect during your first visit at Ottawa Foot Clinic, please call us at (613) 595-9700.

OttawaFootClinic - Intake Form

Please note it is necessary to complete both sides of the following questionnaire.
All information will remain confidential.

Title *

First name *

Last name *

Date of Birth *

Address *

City *

Province *

Postal Code *

Email *

Home Phone or Cell # *

Work #

Person responsible for account (if different)

Phone #

EMERGENCY CONTACT NAME AND PHONE NUMBER

Emergency Name

Emergency Phone

REASON FOR CONSULTATION

HOW LONG HAS THE ISSUE/PAIN BEEN PRESENT

HAVE YOU CONSULTED OTHER SPECIALISTS

TREATMENTS RECEIVED TO DATE

MEDICAL HISTORY

How would you describe your general health?

ExcellentGoodAveragePoor

Do you currently suffer from, or are you being treated for any of the following health conditions?

Do you suffer from any serious allergies (antibiotics, latex, creams, anesthetics)? Please specify or provide a separate typed list.

How did you hear about the Ottawa Foot Clinic?

I have reviewed the information in this questionnaire and it is accurate to the best of my knowledge. I understand that this information will be used by the chiropodist to help determine appropriate assessment and treatment options. If there is any change in my medical status, I will inform the chiropodist. I acknowledge that fees for services are not covered by OHIP and are payable at each appointment. I further understand that 24 hours’ notice is required to reschedule or cancel appointments, and that missed appointments or short notice cancellations may result in a $50 administrative charge.